Category

Outdoors

It has been a couple years since I had the opportunity for a multiday canoe camping trip in the backcountry. I am looking forward to a 4 day trip with a group of friends into the heart of Algonquin Provincial Park in search of some old growth white pines, not to mention some new memories around the camp fire.

We are traveling as a group of 4 with two canoes. So my thoughts have turned to preparations. We are all experienced canoeists and backcountry campers with all our own gear.

When planning a trip it is good to consider traveling light, but also having some elements of redundancy in your kit.Mountain Equipment Co-op has a packing list available on their website for Algonquin newbies.

Here is my personal packing list as well as our communal packing list

Personal Packing List

Map

Compass

Trip Plan left with friends of family

First Aid Kit(s)

Binoculars

Notebook

Pencils

Shoes

Hiking Boots

Socks

Underwear

Bathing Suit

Clothes (short and long sleeve)

Warm sweater

Rain Coat

Shorts/Pants

Lifejacket

Hat

Sunglasses

Sunscreen

Bug Spray

Headlamp

Flashlight

Matches/Lighter/Firestarter

Backpack

Dry Bags

Sleeping Bag

Sleeping Pad

Communal Packing List

Camping Permit

Tent

Tarp

Stove/Fuel

Utensils

Food

Water

Water filter

Toiletries

Toilet paper

Canoe

Paddle /Extra Paddle

Duct Tape

Bailer

Rope

Carabiners

Hatchet/Axe/Saw

*Change of clothes at take-out point.

What would you suggest adding or subtracting to this packing list? (Be sure to leave a comment below) Planning and packing is always an interesting exercise in economy of both space and weight. You don’t want to under pack or over pack, you just want to be prepared. Over the years I have packing for my trips quite refined and rarely come out of the backcountry with clean clothing (which means I used it all as planned).

Below is a video I found of some adventurers who visited a stand of virgin old growth White Pines (Pinus strobus) which can reach over 35 m (or about 10 storeys) in height and about 3 meters in circumference (12 feet).

The majestic white pine (Pinus strobus) is the provincial tree of Ontario. They were historically used for masts on British Royal Navy ships and were specially reserved for the British Crown by being marked by the Broad Arrow. This protected or reserved status eventually led to the Pine Tree Riots in New Hampshire in 1772.

Yosemite has been on my bucket list for quite a while, but sadly I have not yet been able to visit it in person. Tonight while reading the news I came across a report of a child contracting plague (Yersinia pestis) in the Yosemite National Park (1) (2). Details are quite sparse but new reports indicate that this is the first human case of Plague in California since 2006. There have also been some recent cases in the state of Colorado.

In 2012 Yosemite was in the news for another infectious disease, Hantavirus associated visitors who stayed in the Curry Village Tents and High Sierra Camps in July of 2012 (3). Hantavirus is a single-stranded, enveloped, negative sense RNA viruses in the Bunyaviridae family (more on that in an upcoming blog post)(4)(5).

Like plague (Yersinia pestis) Hantavirus is also spread by contact with infected rodents, primarily deer mice.

Plague (Yersinia pestis) has a few main means of transmission which include direct physical contact, indirect contact with contaminated soil or surfaces, fecal-oral transmission from contaminated food or water and vector borne transmission (carried by fleas from rodents to other mammals). The most rare and feared potential modes of transmission are droplet contact or airborne transmission though the evidence for this means of transmission in recent outbreaks is quite low.

Perry and Fetherston (1997) said:

Plague is a zoonotic disease primarily affecting rodents; humans
play no role in the long-term survival of Y. pestis. Transmission
between rodents is accomplished by their associated
fleas. While infection can occur by direct contact or ingestion,
these routes do not normally play a role in the maintenance of
Y. pestis in animal reservoirs. Fleas acquire Y. pestis from an
infected blood meal. Infection in the flea is restricted to the
alimentary canal with other organs and tissues including salivary
glands, reproductive organs, and the hemocele being unaffected.

While doing some reading on this topic I also learned a new term called transovarial transmission, which means transmission of a pathogen from an organism to their offspring by infection of eggs in its ovary. In the case of Yersinia pestis infected fleas, they are not found to exhibit transovarial transmission.

Clinically plague infection in humans tends to be of the bubonic (affecting the lymphatic system) where it spreads and causes the characteristic “bubo” or the septicemic (blood bourne) type. Other rarer and more feared types of plague include pneumonic and meningeal plague.

If diagnosed early Yersinia pestis typically is response to antibiotic treatment with Gentamicin or Doxycycline. The main means of prevention though is avoidance of contact with animal resevoirs such as squirrels, chipmunks and other rodent found around campsites.

Perry and Fetherston conclude:

Consequently,
maintenance of plague in nature is absolutely dependent
upon cyclic transmission between fleas and mammals.

Borrelia miyamotoi, a spirochete that is genetically related to the species of borrelia that cause relapsing fever, has been detected in all tick species that are vectors of Lyme disease.1,2 It was detected in Ixodes scapularis ticks from Connecticut in 2001 and subsequently has been detected in all areas of the United States where Lyme disease is endemic.

Given the widespread distribution of B. miyamotoi, infection due to this agent should be considered in patients who have been exposed to blacklegged ticks in Canada.

What should be stressed is that there is a key methodological difference between these two studies. The first study in the US was looking at human serology tests to, “provide evidence of B. miyamotoi infection and the prevalence of this infection among people in the United States” (NEJM Jan 27 2013). While the latter study in Canada, was looking at specifically at infections in I. scapularis ticks (rather than humans).

Krause et al. conclude (NEJM Jan 27 2013) “The identification of B. miyamotoi antibody in 18 of our study patients, including seroconversion associated with symptoms in 3 patients, suggests that B. miyamotoi infection may [emphasis added] be prevalent in areas where Lyme disease is endemic in the United States”.

The Canadian study found on overall prevalence of less than 1 % for B. miyamotoi. They also noted:

Few ticks were co-infected, however a third of B. miyamotoi-infected ticks and a quarter of A. phagocytophilum-infected ticks were also infected with B. burgdorferi and co-infections of B. miyamotoi and B. burgdorferi occurred more frequently than would be expected by chance.

Overall these were two very interesting articles to read and further remind me of the importance of regular tick checks while working or playing in the outdoor environment. I particularly like the well summarized conclusion in the Canadian paper with the clinical so what statement:

The relatively limited (though expanding) distribution of blacklegged tick populations in Canada [22,28,29] and the lower prevalence of B. miyamotoi infection in these ticks means that at present the risk of infection of humans in Canada would be lower than in parts of the USA [6]. Nevertheless, our study indicated that B. miyamotoi is present across a wide geographic range in Canada, and clinicians should consider B. miyamotoi infection as a possible diagnosis, alongside Lyme disease, Anaplasmosis, Ehrlichiosis, Babesiosis and arboviral infections, in patients suffering from suspected infectious disease who have potentially been exposed to ticks in Canada.

Two great insights from Dr. Singleman were to consider how explorers are likely to die and how to mitigate this risk. He also suggested developing a detailed and logical plan of action that can be defended in the event of an accident. Great food for thought.

Study objective: Compare ibuprofen versus placebo in the prevention of acute mountain sickness incidence and severity on ascent from low to high altitude.

Methods: Healthy adult volunteers living at low altitude were randomized to ibuprofen 600 mg or placebo 3 times daily, starting 6 hours before ascent from 1,240 m (4,100 ft) to 3,810 m (12,570 ft) during July and August 2010 in the White Mountains of California. The main outcome measures were acute mountain sickness incidence and severity, measured by the Lake Louise Questionnaire acute mountain sickness score with a diagnosis of ≥ 3 with headache and 1 other symptom.

Authors conclusions: Compared with placebo, ibuprofen was effective in reducing the incidence of acute mountain sickness.

My conclusions:This small double blinded placebo controlled RCT was well designed and relevant to those who plan to travel from low to high altitude. Currently the only medications with indications for prevention of AMS are Acetazolamide and Dexamethasone both of which can be associated with potentially serious side effects and safety concerns.

The authors main conclusion supporting the use of Ibuprofen is based on Table 2.

My main concern is the relatively small overall sample size and wide confidence intervals for the difference in AMS severity and potential for overlap (meaning no true difference) between AMS severity in the placebo and ibuprofen groups. One surprising finding for me was that the Ibuprofen group had a similar incidence of headache (0.6 (0.2–1.6)) compared to the control group, but decreased incidence of GI complaints (OR 0.3 (0.1–0.8)) which is the opposite of what I would have expected. That said the difference in headache finding was not statistically significant.

My bottom line is that until I see further studies supporting the efficacy of Ibuprofen for the prevention of AMS, I will not be endorsing this prevention strategy. While the risk of adverse events is quite low, as would be the cost of treatment, I still remain skeptical. What I would like to see in future research is further validation of this finding in a larger study. I would also like to see a well designed head-to-head non-inferiority double blinded RCT comparing Acetazolamide, Dexamethasone and Ibuprofen, although given the difficulties of recruiting adequate numbers of participants for altitude related research, I won’t be holding my breath.

Rationale: You can be of no help to others, if you injure yourself. Be sure to use personal protective equipment and ensure your own safety and that of your team members when trying to provide patient care in a wilderness context.

Rule 2: Always use the other guys stuff first.

Rationale: If you need to make improvised litters or splints for evacuating a patient from a wilderness setting, use their gear if possible.

Rule 3: Replace your sweat, not your water.

Rationale: To avoid electrolyte derangement it is best to replace fluid with substances which contain electrolytes. If the patient has gastroenteritis consider the use of oral re-hydration solutions.

Rule 4: Hypothermia is a leadership issue.

Rationale: Hypothermia occurs when the exposure to cold overwhelms the body’s ability to produce and retain heat. Proper clothing for the environment, along with adequate nutritional intake can go a long what in preventing hypothermia.

Rule 5: If you don’t know a knot, tie a lot.

Rationale: While having proper knowledge of knot tying is critically important in mountaineering and sailing, if you lack the specific knowledge to tie sound knots, extra knots can provide redundancy against potential knot slippage.

Rule 6: Proper preparation prevents piss poor performance.

Rationale: Just like in a resuscitation, wilderness medicine scenarios can devolve into a scene of chaos. The person who is able to control that chaos is the person who is able to do what is needed for their patient and team. Maintaining composure and control will ensure your safety and your patients safety.

Yosemite time lapse made by photographer Shawn Reeder, with music by Shaun Paul. One of the most spectacular time lapse movies I have ever seen. It will make you want to go for a hike. Words cannot describe the beauty of this video. Check it out for yourself.